It is a very British thing to not been seen to take sides and be impartial and balanced, listening to both sides. But there comes a point when the talking is done and to continue to maintain neutrality is to live out the oft ill attributed maxim of Edmund BurkeThe only thing necessary for the triumph of evil is that good men do nothing.

Or, to quote a more modern voice on this issue:Dark times lie ahead of us and there will be a time when we must choose between what is easy and what is right.JK Rowling

So it was that on Monday (14 January 2019), the Royal College of Physicians of London issued a press release which announced that they were to poll their 35,000 members and fellows in February to ask whether they supported a change to the law on ‘assisted dying’ (or more accurately, euthanasia and assisted suicide).

Now, it is generally a good thing to poll one’s members as a representative body. But this poll has some real question marks around it. Firstly, this is the third poll since 2006, and both those previous polls (the last in 2014) did not show a significant shift in opposition to assisted dying amongst the college’s members. It is not clear that anything has significantly changed since that last poll.

Secondly, it is proposing that the college moves to a neutral position on the issue – neither for nor against. There are major implications for such a shift in position, and I will come to those in a minute. However, the college has said that whatever the finding of the poll of its members, it will move to this neutral position, unless a two thirds majority of those responding disagree.

It seems bizarre (if not undemocratic) to have vote to change policy where the policy change is a fait accompli. So even if 60% of RCP members opposed this move to neutrality, it would still go ahead because there was not a ‘supermajority’ opposed.

Supermajorities like this are very unusual in British institutions, and usually only come into effect if they are required for a major constitutional or policy change rather than against it. At the last RCP poll on the issue, as stated in their press release, over 58% of members and fellows opposed euthanasia, 44% felt the college should remain opposed as part of its policy, and only 31% felt the college should adopt a neutral stance. Less than one in four were in favour of supporting euthanasia. So, it is hard to see where the democratic mandate for this change has come from. Certainly not from the membership!

Thirdly, if the RCP chooses to go neutral on this particular issue, it will be giving euthanasia and assisted suicide a status that no other issue enjoys. Why should assisted suicide and euthanasia enjoy this level of attention, when there is no legislation pending in either Westminster or Holyrood?

If the RCP does go neutral in March, it will give succour to those seeking a new attempt to change the law at parliamentary level. Parliament strongly rejected assisted suicide the last time it was debated in the Commons in 2015 (by a two thirds majority of MPs on a free vote). However, those seeking a change in the law have not given up. They may be emboldened as a general election since that time has seen some changing of the guard in the Commons. The possibility of at least one medical body shifting their stance on the issue would further give euthanasia proponents the opportunity to say (erroneously) that there is a shift in medical opinion on the matter. Notwithstanding that the majority of doctors remain opposed.

Furthermore, by going neutral, the RCP will be forced to remain silent and take no part in any debate. Physicians would have no collective voice.

Fourthly, as already stated, the majority of doctors in the UK continue to be opposed to a change in the law. Polls of their members in the last five years by both the RCP and the RCGP have shown no appetite to go neutral or support assisted suicide and euthanasia by doctors. Palliative Medicine Physicians, who deal with the dying on a daily basis, are 82% opposed to any change in the law. The BMA briefly adopted a stance of neutrality in 2005/2006. It subsequently overturned that decision. Most recently in 2016 here was an attempt to once again move it to a neutral stance, which was squarely defeated by a two-thirds majority.

Why choose to go neutral where there is such a strong opinion against euthanasia amongst doctors?

Fifthly, assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella. Neutrality would be a quantum change for the profession and against the international tide.

When the Canadian Medical Association (CMA) and the Royal Dutch Medical Association (KNMG) tried to get the World Medical Association to change its stance of opposition to euthanasia in 2018, they got little traction and withdrew their motion.

So, while some jurisdictions have introduced legalised euthanasia (including Canada and the Netherlands), most medical bodies worldwide remain strongly opposed. This would move the RCP out of step with many of its allied colleges and professional bodies in most of the rest of the world.

Finally, to drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic recession could be highly dangerous. With many families and the NHS itself under huge financial strain, the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

Were the RCP to drop its opposition, and as a consequence a law were to be passed in the next few years, it would leave the medical profession hugely divided at a time when, perhaps, more than any other time in British history, we need to be united as advocates for our patients and for the highest priorities in a struggling health service.

In short, when it comes to such a divisive topic as assisted suicide and euthanasia, taking a neutral stance is not a credible option for professional bodies like the RCP. If they are for ‘assisted dying’ they should come out and say so openly and justify why they are defying their members and global medical opinion to back removing and weakening laws that protect the most vulnerable. Otherwise they should continue to reflect the views of the majority of their members and stand against changing laws that protect their patients.

]]>https://cmfblog.org.uk/2019/01/15/assisted-suicide-the-royal-college-and-the-myth-of-neutrality/feed/0A good day to bury bad news? New CANH guidance released by BMAhttps://cmfblog.org.uk/2018/12/13/a-good-day-to-bury-bad-news-new-canh-guidance-released-by-bma/
https://cmfblog.org.uk/2018/12/13/a-good-day-to-bury-bad-news-new-canh-guidance-released-by-bma/#respondThu, 13 Dec 2018 15:19:30 +0000https://cmfblog.org.uk/?p=11988When Jo Moore infamously sent a memo saying in effect that 11 September 2001 was a good day to bury bad news, she inadvertently lifted the veil on a time honoured practice of releasing news and reports in the midst of major national or world events in the hope that the news media fail to pick up on them or make enough of them to garner the public’s interest.

So it was that in the midst of one of the most tumultuous days, in the most tumultuous week (yet) of one of the most tumultuous years in recent British politics, the British Medical Association (BMA) and the Royal College of Physicians (RCP) chose to release their guidance on the withdrawal of clinically assisted hydration and nutrition (CANH) from patients with prolonged disorders of consciousness (PDOC). Only the Guardian released a well pre-scripted story to mark this – the rest of the media were focussed elsewhere!

CMF made a submission to the BMA when it was seeking evidence for its new guidelines – needless to say we had significant concerns about what was then being proposed. We have also blogged before on our concerns about this guidance, coming after a Supreme Court ruling in July this year that such decisions no longer need to be taken to the Court of Protection but can be left in the hands of clinicians, in consultation with families. The new guidance replaces the rules established after the Tony Bland case in 1993. Under them the Court of Protection approved the removal of CANH from over 100 people.

This latest ruling affects up to 24,000 patients with two types of PDOC – permanent vegetative state (PVS) and minimally conscious state (MCS). However, in a worrying development the BMA have extended the guidance to include those suffering with severe strokes and dementia, so many, many more patients could be affected in the long term.

People with PVS (awake but not aware) and MCS (awake but only intermittently or partially aware) can breathe without ventilators but need to have food and fluids by tube (CANH).

These patients are not imminently dying and with good care can live for many years. Some may even regain awareness. But if CANH is withdrawn, then they will die from dehydration and starvation within two or three weeks.

Until last year all cases of PVS and MCS have had to go to the Court of Protection before CANH could be withdrawn.

The BMA brought forward their guidance following the ruling in two cases last year (known as M and Y). The High Court ruled that if the relatives and medical staff agreed that withdrawal of CANH was in the patient’s ‘best interests’ then the court need not be involved.

The Official Solicitor appealed this decision to the Supreme Court , but the judges upheld the decision of the High Court.

The effect of this his new guidance is that it makes no difference in principle between turning off a ventilator and removing a feeding tube for food and water, as both are now regarded as ‘forms of medical treatment’. It also fails to treat patients with PVS and MCS differently to people with ‘severe stroke’ a ‘degenerative neurological condition’ or ‘other conditions with a recognised downward trajectory’.

It fails to recognise the latest peer reviewed research from the American Academy of Neurology (AAN), the world’s largest association of neurologists and neuroscience professionals, which just this summer published a paper detailing the difficultly in reliably diagnosing the extent of brain damage in patients.”

A summary of this study together with an accompanying literature review was published online in August 2018 in the medical journal Neurology. An accompanying press release summarises the main points.

It found four in 10 people who are thought to be unconscious are actually aware. One in five people with severe brain injury from trauma will recover to the point that they can live at home and care for themselves without help. And went on to recommend that the term PVS should be dropped.

It is important that doctors and clinicians follow the latest medical practice, and this should be based on high quality evidence. What this highlights is the complexity of reliably diagnosing PVS and MCS. This is why this guidance is not just outdated but is error ridden.

It also misses the important ethical point that there is a clear difference between turning off a ventilator on a patient after brain death and removing CANH from a brain-damaged patient or someone with a degenerative neurological condition, or even those on a ‘downward trajectory’. Our concern remains that this guidance, while perhaps initially seeming compassionate and less burdensome than the previous regulations, actually removes protection from highly vulnerable patients and widens the scope of those who are affected. Some of these patients may be more aware and have a better chance of recovery than is initially apparent. It also opens the door a crack wider to legalised euthanasia in the UK, which may be why Dignity in Dying has been so welcoming.

]]>https://cmfblog.org.uk/2018/12/13/a-good-day-to-bury-bad-news-new-canh-guidance-released-by-bma/feed/0Christian doctors unite worldwide to challenge WMA on conscience rightshttps://cmfblog.org.uk/2018/09/14/christian-doctors-unite-worldwide-to-challenge-wma-on-conscience-rights/
https://cmfblog.org.uk/2018/09/14/christian-doctors-unite-worldwide-to-challenge-wma-on-conscience-rights/#respondFri, 14 Sep 2018 10:26:04 +0000https://www.cmfblog.org.uk/?p=11946The International Christian Medical and Dental Association (ICMDA) has called on the World Medical Association (WMA) to protect doctors’ conscience rights on abortion and euthanasia.

ICMDA, which unites national associations of doctors and dentists in over 80 countries, was responding to a move by Canadian and Dutch doctors to challenge the WMA’s longstanding commitment to protecting freedom of conscience at a meeting in Iceland later this year.

Since 1947 the WMA has published a number of key policies, which have shaped medical ethics including the Declaration of Geneva – the successor of the Hippocratic Oath (1947) – the International Code of Medical Ethics (1949,) the Declaration of Helsinki on research involving human beings (1964), the Declaration of Tokyo commanding physicians not to participate in torture or degrading treatment (1975) and the Declaration of Malta on Hunger Strikers (1991).

But at its upcoming Medical Ethics Conference (2-4 October 2018) and General Assembly (3-6 October) in Reykjavik, it will be debating proposals that would significantly weaken its stance on the freedom of conscience rights of doctors with respect to abortion and euthanasia.

Its current position on abortion makes the freedom not to be involved in any aspect of abortion quite clear. The new proposal limits this right only to actually performing an abortion, but not to assistance, referral, oversight or more peripheral involvement.

The statement also makes it clear that doctors have an obligation to intervene when there is a threat of serious injury or damage to the woman’s health. Again, this could require doctors to perform abortions on grounds of the woman’s mental health, a caveat that could lead to doctors being pressurised to perform abortions on demand.

At the ICMDA’s General Assembly during their quadrennial World Congress in Hyderabad in August 2018, the membership unanimously supported a statement asking the WMA to reconsider these changes, and in particular to make it clear that freedom of conscience should apply to the right not to refer or advise, and that the doctor’s obligation to perform an abortion was to protect the physical health of the woman.

In addition, while the WMA has a policy of not supporting euthanasia and assisted dying, ICMDA has also asked that they make it explicit that doctors in those countries which permit euthanasia should have the right to conscientious objection to both participation and referral.

It is concerning that a body, set up to promote medical ethics and preserve freedom of conscience in the wake of the revelations at the Nuremberg trials, is under pressure to undermine freedom of conscience in this manner.

We can only hope and pray that the voices being raised to maintain such freedoms will be listened to, because to override freedom of conscience in one area for one group is threaten such freedoms for all.

]]>https://cmfblog.org.uk/2018/09/14/christian-doctors-unite-worldwide-to-challenge-wma-on-conscience-rights/feed/0Happy Birthday NHS: Let’s not let a national good become a national godhttps://cmfblog.org.uk/2018/07/05/happy-birthday-nhs/
https://cmfblog.org.uk/2018/07/05/happy-birthday-nhs/#respondThu, 05 Jul 2018 09:47:55 +0000https://www.cmfblog.org.uk/?p=11887Today (5 July 2018) marks seventy years since the world’s first, free-at-the-point of delivery, universal access, national healthcare system was launched. Britain’s National Health Service (NHS) has become so much a part of the fabric of British life and culture in those seven decades that it is regularly cited in surveys of the British public as the one thing that they are most proud of about the country.

If you live in the UK and didn’t know any of this, it is likely because you have neither read a newspaper, surfed the web or watched television for the last few weeks. If you don’t live in the UK, you may wonder what all the fuss is about.

At the height of the Second World War, British Civil Servant Sir William Beveridge produced a report arguing for a nationalised insurance service for welfare and healthcare that would be accessible to all on the basis of need rather than ability to pay. The principle of caring for those not able to pay for themselves was not new, and indeed a slew of charitable (often church-run) hospitals had been doing this in Britain and most of Europe since the Middle Ages. But it was the idea that this would be delivered by the state in setting up a national health service, funded out of general taxation, with no means testing that was so radical at the time.

However, it would not be until 1948, three years after the end of WW2 with a nation still in a painful process of rebuilding itself after six years of brutal conflict, that the NHS would finally be launched. Overnight charitable and for-profit hospitals were nationalised, with only local family doctors (General Practitioners or GPs as they are now known) remaining semi-independent as contracted private providers and the first port of call for those seeking treatment.

Doctors resisted this radical change initially, fearing a loss of private income. Many church hospitals and Christian doctors also had anxieties about the impact on their freedom to practise in the name of Christ. However, the public were and remain deeply attached to the idea that all citizens, regardless of class and wealth could now get world class healthcare. In time the professions all came around to the idea. Today the medical profession and the churches remain some of the NHS’s staunchest defenders.

Indeed, that principle of making healthcare universally accessible to all has become globalised. The UN Sustainable Development Goals (SDGs) have enshrined the goal of each country moving towards Universal Health Coverage (UHC) as one of the fundamentals to achieving sustainable health for all people everywhere at all ages. And the British Government has been busy exporting the NHS model (especially its GP led primary care model) to countries as diverse as the United Arab Emirates and the People’s Republic of China!

However, since the day that it started, the demand has outstripped the resources of the NHS. Initially this was because those who had lived with ailments untreated because of cost could now freely seek treatment. In time it became apparent that this initial surge in demand was not going to go away, and if anything was increasing.

Over the decades, the NHS has also become a victim of its own success. As maternal, infant and child mortality rates plummeted, the population began to grow. As public medicine developed, so population-wide preventative measures reduced disease incidence across the nation and across all social classes. As care for the diseases of old-age improved, and social care for the elderly became part of the wider welfare provision, so life expectancies began to rise.

That growing and increasingly elderly population now need more long term social and medical care than ever before. As child birth grew safer and fewer children died young, so birth rates began to drop. The paradox of wealthy nations is that there are fewer and fewer young, working people to fund the care needs of the elderly.

Furthermore, the costs of new medicines and medical technologies has continued to escalate. As a result of all of these pressures, the NHS now finds that its costs are spiralling upwards as funding either stagnates or shrinks.

While it is a broadly efficient system, and offers the best palliative care on earth, the NHS has poorer outcomes for many major diseases than many other developed nations. It can be bureaucratic, uncaring and incompetent. The Francis Report showed how readily a caring institution can lose its focus and priorities, to deadly effect. The NHS is not the best healthcare system on earth, much as we like to think that it is. This deep national faith in the NHS can become resistant to reform and change.

However, ask anyone in Britain about the NHS today, and they will readily recognise its problems and limitations. They may even have horror stories to share about when care went wrong for a friend or family member. But they will also tend to express an admiration for the institution and a belief in its founding principles. As Nigel Lawson once said, the NHS is ‘the nearest thing the English have to a religion’. That could be said of the Scots, Welsh and Irish too! Any British politician who seeks to ignore or challenge this, risks their political career. This too can make real reform very difficult.

Is it also a sad reflection on our national priorities? Healthcare free at the point of need to all regardless of means is a good, godly principle that many Christians would endorse. In a modern, industrialised country, probably only the state is big enough to coordinate such a service. But in the process the volunteerism, charitable instincts and spiritual motivation of many who would care for the sick can be pushed to one side. When the NHS was set up, it embraced church-run services, and hospitals and did not interfere overly much in their ethos and organisation. That has changed, and today faith is pretty much banished from the workplace and spiritual needs are poorly, if ever, addressed for many patients.

Furthermore, in a culture that has abandoned Christianity, the hope of staving off death and suffering has replaced trust in Christ and the resurrection. Our focus has become distorted, seeking to postpone death rather than embracing life in all its fullness. Or, when suffering becomes too much, embracing death through assisted suicide rather than finding hope. Have we turned a national good into a national god?

We continue to support the NHS, but not uncritically, especially if it is to survive as a healthcare system for the next seventy years!

]]>https://cmfblog.org.uk/2018/07/05/happy-birthday-nhs/feed/0NHS crisis – the role of the extended familyhttps://cmfblog.org.uk/2018/02/08/nhs-crisis-the-role-of-the-extended-family/
https://cmfblog.org.uk/2018/02/08/nhs-crisis-the-role-of-the-extended-family/#respondThu, 08 Feb 2018 16:03:22 +0000https://www.cmfblog.org.uk/?p=11803Discontent with the current state of the NHS, and in particular with its funding, has rumbled on with marches at the weekend; yet more proposals for a ‘hypothecated NHS tax’ to raise funds (and the counter arguments); pledges that more is being given than ever before, and even tweets from Donald Trump claiming that the NHS is a collapsing system!

Before the 2015 General Election, Simon Stevens, head of NHS England, had called for a minimum £30 billion extra funding by 2020/2021 to just maintain services at the current level. With cost savings, this was still going to come in at an extra £8 billion. The reality is that even this was almost certainly an under estimate, and the Kings Fund now reckon the actual increase in funding offered by the government really only came to an extra £4.6 billion

Calls for a rethink of not just how we fund the NHS, but how we run it have been around for years. It just feels even more acute at the start of 2018 than on previous occasions.

Which rather leaves one to wonder in just what kind of state are the other health systems of the world? It also leaves me asking why British politicians are looking abroad for answers to what ails the NHS? In fact, since 2013, the British Government has been trying to export the NHS model of care worldwide, especially into Asia and the Middle East.

However, the NHS is definitely struggling – we hear this at CMF regularly from our members at all levels and in all branches of the system. Something needs to change for the sake of the health and wellbeing of our nation.

There are a number of directions we could take NHS funding, and Howard Lyons has written a detailed and thoughtful account of these in CMF’s journal Triple Helix. We could follow the social insurance system of France and Germany (which seems to work quite well, but overall not much better than the central tax model of NHS); or a localised tax and funding arrangement such as one finds in Denmark and other parts of Scandinavia (whose healthcare systems often fare much better than ours); or we could rely more and more on private insurance, as is the case in the US or much of the Middle East, with the state just running a health system for those who cannot afford to buy it.

By and large there is no real taste for (indeed, active opposition to) the latter option, and the British political system likes to run things from the centre, so the Scandinavian local tax system is probably not going to be popular here either. The move to a centralised social insurance system also has few fans politically in the UK.

However, it is not just that the funding of the system is in crisis. Another, even more basic issue is how health services actually function I would argue that one long standing problem is that we have seen health in separate category to social welfare, social care, schooling and childcare. In Catholic and Protestant Europe of past ages, these social needs tended to be under one umbrella, usually a joint venture between the state the church and the family.

Granted, 6th century Alexandria or 16th century Geneva are very different societies to our own – the state was smaller, ruling a smaller community and with significantly fewer responsibilities than today. The church was bigger – in Calvin’s Geneva, church membership was pretty much compulsory! Medicine was very limited, and for many ailments the best that could be offered was good nursing care and prayer. Finally, the family was the centre of social support and care networks – the state had next to no role, and the church just picked up those without family to care for them.

Thankfully today we can deal with complex medical needs incredibly well and we have a good social welfare infrastructure, and the State has a key role in coordinating all of this. Sadly, we also have more family breakdown, more social isolation, especially among the elderly. In fact, loneliness in modern Britain is such a serious problem (and a significant contributory factor in many physical and mental health needs) that the government has just appointed MP Tracey Crouch as the first Minister for Loneliness!

There is such a wealth of evidence for the role of stable families in physical, mental and social health and wellbeing that it continues to beggar belief that no government has really bitten the bullet and seen major policy shifts to support families. There are many of proposals for progressive policies that could make a real impact, but they remain politically unpopular. Not because the vast majority of the British public oppose them – quite the opposite, as David Goodheart suggests in his recent book Road to Somewhere. The problem is, as he sees it, that the ruling elite have developed a distaste for family friendly policies – it runs against the academic climate in which they were raised where the family was seen as the source rather than the solution to social ills.

Most of the population do not share those beliefs. Instead they have seen policies that have weakened the ties of marriage and family life among the poorer sections of society. Marriage in modern Britain has become mostly a middle-class institution, accruing its benefits to those who already have money and education on their side. Weaker families lead to more health and social problems across society – with recent estimates suggesting the economic costs to the UK taxpayer alone are around $51 billion a year.

Policies that support marriage and family life, intergenerational households and family friendly working practices could have a real impact – not just in keeping families together, but in increasing the prosperity and wider cohesion of families. While the state cannot make a failing marriage work or force people into inter-generational households, it can do a lot to make it easier for families to stay and live together. Many are arguing that current policies are having the opposite effect.

Whatever funding model we settle on for the long term, we need prosperous families to contribute to the taxation or insurance system we use. If we want to reduce the backlog of elderly people in hospitals needing social care to be discharged, we need families that have the capacity and the space to care for them – why do we build so many small homes for couples and for one or two children, rather than larger houses that suit inter-generational families?

Some families will fail, despite the best efforts of governments and other institutions. We will continue to need a welfare system to pick up those subsequently left behind, but we need to fund it properly, so that those providing the care are properly rewarded for the socially vital task that they are undertaking.

Adolescents, even in the most caring families, will face mental health problems that need professional interventions. In fact child and adolescent mental illnesses are a growing problem in western societies. So, we need properly accessible and well-resourced child and adolescent mental health services, not the current barely functioning service that is failing our children and teenagers despite the best efforts of the massively overstretched professionals.

But healthy, stable, secure families, especially in poorer communities will reduce the need for such services.

In the Bible the family is the centre of the community – the bet ab – literally the ‘father’s house’ or the household. Not a nuclear family, but an extended family of children, their spouses, grandchildren and grandparents, guests, strangers, foreigners. All sharing life together, caring for one another and for the vulnerable in the wider society. With no welfare or formal schooling, everything happened in and around the household. In Calvin’s Geneva, it was the family that was held responsible for the needs of their vulnerable members, the church and state only stepping in when they failed or were not present.

And while the primary purpose of the church is to bring God’s people together to praise their Creator, learn to live the life of Christ together and to proclaim the gospel, it also has a key role in living that life out through supporting caring for one another and the wider community.

While the family and the church cannot solve all of society’s ills, they must be a part of the solution.

]]>https://cmfblog.org.uk/2018/02/08/nhs-crisis-the-role-of-the-extended-family/feed/0Global Health Challenges for the Year Aheadhttps://cmfblog.org.uk/2018/01/30/global-health-challenges-for-the-year-ahea/
https://cmfblog.org.uk/2018/01/30/global-health-challenges-for-the-year-ahea/#respondTue, 30 Jan 2018 12:47:43 +0000https://www.cmfblog.org.uk/?p=11791A year ago, I blogged about some of the global health challenges that Christians and Christian organisations would be facing in 2017. At the start of 2018 I thought it would be good to revisit some of those issues and look to others that are emerging in the coming year.

Changing Aid Climate

As predicted by almost everyone, the new Trump administration has proposed significant reductions in the US aid and development budget. This includes reducing funding for work on containing infectious disease outbreaks by the Center for Disease Control (CDC) in Atlanta; given the World Health Organisation’s poor track record on this issue, the withdraw of the CDC’s support could further weaken the global response to the next major infectious disease outbreak.

However, the issue that is at the top of most of the development community’s concerns it that the Trump administration has reinstated the so-called Mexico City Policy or Global Gag Rule. This means that USAID (US department for Aid and International Development) requires any aid agency that receives US funding to commit to not providing, counselling or informing women about abortion as a family planning option. This has already slashed funding from Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF) to the tune of $80 million and $100 million respectively. But the impact is wider, hitting national and non-US agencies, and some estimate that over twelve hundred NGOs will between them lose $2.2 billion in funding. While other governments and movements have increased funding to some of these agencies to the sum of around $450 million, the shortfall remains significant.

This will have two impacts. A lot of family planning services continue but are being provided by agencies that do not provide or counsel abortion. In other areas, services will be lost altogether or significantly reduced. While this is causing outrage in much of the development community, faith-based organisations are continuing to provide effective services, many funded by USAID, and many stepping into the breach left by MSI, IPPF and their like. The consensus that IPPF and MSI have created about family planning is being challenged. In fact, most countries, and indeed the UN itself do not include abortion in family planning definitions. Furthermore, the track record of bodies like IPPF and MSI is increasingly in question. While many in the development community are up in arms about the current US funding policy, the impact on maternal and child health may well be less disastrous than many claim.

Conflict

At the start of 2017, the war in Iraq and Syria was the big concern. Forcing millions to flee and become refugees in surrounding nations, Europe and beyond, while millions more left as internally displaced people (IDPs) within their war wracked countries. By the end of the year, while that war has begun to wind down, the biggest health crisis has shifted to Yemen where over a year of civil war supported by regional powers (and indirectly by many western and eastern governments including the UK) has led to the biggest outbreak of cholera on record, the re-emergence of long controlled infectious diseases such as diphtheria, and the near total infrastructural devastation that means the country could take a generation or more to recover, as and when the fighting ceases. At the time of writing, the prospects of this situation are so remote as to be laughable, but it is no laughing matter.

Meanwhile, civil wars and conflicts in Central African Republic and South Sudan leave many unable to grow food, get clean water or access health services, while also generating refugee situations of their own.

The persecution of the Rohingya in Myanmar has also created a major humanitarian crisis on the Bangladeshi/Myanmar borders that may rumble on for years.

Health Workforce

This is no new challenge, but it has once again come to the fore that there is a huge shortfall of health workers across the developing and developed world. In the UK we are seeing one in ten nursing vacancies unfilled and a shortage of General Practitioners and junior doctors. The US and other western nations are facing comparable shortages. This creates an opportunity for millions of doctors, nurses and other skilled health workers from developing nations to migrate, leaving their own nations even shorter of professionals than the West.

Another, largely ignored issue within this is that most of these health workers are women (at least 75%). While the #MeToo movement started in the West with celebrities, the realities not just of sexual harassment, but of discrimination and lack of access to education, good pay and chances for promotion that women face in many parts of the world mean the health workforce is still often ignored and under-resourced. As I have said elsewhere, just increasing our investment in training nurses has an impact not only on health, but also on development and the status of women in society. But the same challenges face midwifery, medicine and other health professions, and one of the issues at the heart of this is the status of women and whether female healthcare leaders will be listened to at national and global levels.

At present, the global health workforce is short of 18 million trained health workers. To achieve the SDGs by 2030 the WHO reckons the world needs another 40 million health professionals. Without adequate pay, training, working conditions and recognition, this simply won’t happen. And this is not just a developing world issue – as the current NHS winter crisis reminds us, the wealthy nations of the world are also falling short of health professionals at an alarming rate. The only difference is that we can afford to poach them from poorer countries, exacerbating the problem.

And the good news?

Has it all been bad in the past year? And is the future all grim? Leaving aside the natural pessimism of the British in January, especially when faced with the catalogue of disasters and challenges I have listed above, there turn out to be many encouragements and guarded reasons for optimism.

Firstly, some disasters never happened. A famine in South Sudan was averted, and overall the chances of people dying of famine has dropped globally to 0.06% of the figure in the 1960s. Famine early warning systems, better coordination of aid and emergency relief have all reduced the incidence of famine. Wars have killed fewer people in the last year. The war against ISIS has begun to wind down, and while the wider civil war in Syria may well wind back up with a focus on Syria, Iraq and now Turkey trying to supress various separatist groups on their borders (in particular the Iraqi and Syrian Kurds in the north of the region), overall the fighting has (for now) abated and reconstruction begun (at least in Iraq). This could all change at the drop of a bomb, of course, and the regional conflicts across the globe are almost all far from resolved. And the West’s tensions with North Korea threaten a conflict on a global scale!

We have plenty of reasons to give thanks, but also to pray for peace.

We also saw fewer deaths from natural disasters, such as floods, droughts, and (despite the awful hurricane seasons in the Gulf of Mexico last autumn) high winds.

Secondly, the global community is making progress on coordinated preventative health programmes. Vaccination rates are at their highest ever (86%) for the major infectious illnesses (diphtheria, pertussis, measles, Hepatitis B and rotavirus). New Zealand has completely eliminated measles in the last year, joining the UK, Australia and the Americas. Overall deaths from measles have now dropped from 550,000 in 2000 to 90,000 in 2016. It is significant progress, but there is still a way to go. Meanwhile, only 19 cases of wild poliomyelitis were recorded on Earth in 2017.

Life expectancy continues to rise in most countries (the UK being a notable exception over the last few years, where life expectancy is stagnating and even declining). Infant and maternal mortality rates are also coming down. Malaria vaccines will be rolled out to children in some of the most at-risk regions, and clinical trials of an HIV antibody that offers the potential of an effective preventative measure begin soon.

Finally, poverty is being reduced. Fewer people are living on less than $2 (£1.50) a day – about 200,000 people are being lifted out of extreme poverty every day. This is mostly due to a robust and currently booming global economy. The potential of poorer nations and communities to benefit from a strong global economy remains a challenge and an issue of social justice. One of the surest ways to improve health is improve personal and national wealth. Literacy has continued to increase, as has access to primary education (especially for girls) – both linked with increased health and wellbeing for communities.

Challenges for Christians

We are also unpopular because we are challenging the consensus on issues like gender, sexuality, family planning, personal autonomy and freedom of conscience. The western aid and development movement do not particularly like working with us, and while bodies like the WHO and UN are recognising the need to work with faith communities, Christians who hold to their values and beliefs are more likely to be marginalised. Yet the narratives of the secular West are increasingly challenged and other voices are being heard. I also suspect that the relevance of the WHO and UN in global health will change in the coming year.

In 2017 we remembered the 500th anniversary of the start of the Reformation. Its impact on the world continues to this day, not least in medicine and healthcare. Christians of all theological persuasions continue to minister to the poor and sick in the most deprived areas of the world because of our faith in a Saviour who reached down into the mess and misery of rebellious humanity to reconcile us to God. Let’s continue to challenge the world’s values not so much by our words, but by our actions.

]]>https://cmfblog.org.uk/2018/01/30/global-health-challenges-for-the-year-ahea/feed/0Reshuffling health and social care – finding models that workhttps://cmfblog.org.uk/2018/01/12/reshuffling-health-and-social-care-finding-models-that-work/
https://cmfblog.org.uk/2018/01/12/reshuffling-health-and-social-care-finding-models-that-work/#respondFri, 12 Jan 2018 12:48:02 +0000https://www.cmfblog.org.uk/?p=11749Monday’s cabinet reshuffle has opened up some interesting possibilities. With Jeremy Hunt not only staying on as Secretary of State for Health, he has now widened his official remit / title to Secretary of State for Health and Social Care, with the current Department of Health being accordingly renamed the Department of Health and Social Care (DHSC).

Leaving aside that Hunt is not popular with health professionals (although I challenge anyone to name me any Secretary of State for Health who HAS been popular with health professionals!) and that in reality, social care has been a part of his remit for some time, this is, we hope more than just a change of title. We hope that it shows a recognition within the government that to reform healthcare in the UK, we must also reform social care.

It is a bit of a no brainer really – the two are so interlinked. Indeed, the Head of NHS England announced several local pilots integrating health and social care last summer. It is not a new idea!

At the same time as the NHS seems to be facing its worst winter crisis in a long time, if not its worst ever, many are calling for a cross party rethink on how we fund and deliver care in the country, and many are now calling for a cross-party Royal Commission to do this. Certainly, Hunt will be taking the lead on a new green paper to address health and social care reform in the coming months. So, reform of one kind or another would seem to be afoot.

Many fear that the ongoing reforms of the last two administrations are an attempt to ‘privatise’ the National Health Service (NHS) by stealth. These anxieties, from left wing media and health professional bodies, stem from an anxiety that subcontracting out services to ‘for profit’ companies risks diluting or even destroying the NHS ethos of care free at the point of delivery to all according to need rather than ability to pay. These voices argue that the profit motive leads to cut corners and compromises that do not benefit patients. More funding and more state sector intervention is the only hope of saving the NHS and its core ethos, they argue.

On the right, the concern is that a growing bill for providing services cannot be met, and a new, more cost-efficient health service is needed, with less bureaucracy. Market competition is far more efficient than state control, they argue, and so will lead to a more efficient service without compromising care.

Both are right and wrong, I would suggest. Right in much of their diagnoses, wrong in most their prescriptions.

Markets are great for products we buy and sell – they ensure that there is a price that reflect the need for the product and the cost of its production. Health, however, is not a product or a commodity – it is a fundamental of human existence. Healthcare is therefore not a product, it is an essential service that all of us will need to access to maintain our health at some point or other in our lives. More than that, the provision of health and social care is an act of social solidarity that says all human lives matter and that the quality of those lives matter. Ensuring people are cared for and treated well and with dignity is a core act of social solidarity.

The state has an important role in coordinating and distributing essential services and resources, responding to and identifying needs at a macro level through policy and infrastructure in a way that the private sector cannot. But central planning is a blunt instrument and does not easily allow for innovation and creativity. It can be inflexible, and can fail to respond to the difference in needs and circumstances as a very local level.

The German sociologist Tönnies pointed out that in pre-Enlightenment Europe mutual social solidarity was provided by the church, as a local, national and a supra national network and institution. Societies looked after those in need in their community through a variety of institutions and networks, many founded in the church. In many parts of this country, the church still fulfils that role.

Post Enlightenment, there was a move towards more secular networks and institutions to continue this, but also a shift from what Tönnies termed Gemeinschaft (community, mutuality, social responsibility, loyalty, friendship and love) towards Gesellschaft (a group of individuals bound together by utilitarian interests and necessity). The profit motive that is one of the big ties in Gesellschaft removed the sense of mutual care, responsibility and social solidarity. It puts career at the centre, and denies or minimises a sense of vocation, or calling to health or social care.

Socialist and free market systems are both guilty of promoting Gesellschaft at the expense of Gemeinschaft. The barren nature of Soviet era healthcare in Eastern Europe shows this at its most stark – universal, technically competent (for the most part) but reducing people to machines to be fixed and put back to work. It ignored the fact that people have complex hinterlands and responsibilities as well as needs. The free market approach to healthcare in some Western nations displays a similar, bleak utilitarianism that ignores the social and spiritual nature of human beings.

The NHS, amazingly, seems to hold these two ideas in tension – maintaining an ethos of service and social solidarity while operating a modern, professional pay and career structure. How else can we explain the number of staff working well over and above the hours for which they are paid just to keep services running, especially in the current crisis? The staff believe in the NHS, value it and through their time and effort, invest in it as a social institution.

This marrying of the vocational and the professional can probably be laid at the feet of such luminaries as Florence Nightingale who saw no contradiction between the two. And probably to many other social reformers of the 19th and 20th century as well, including the father of the NHS, Aneurin Bevan. While Bevan was an atheist, many of the other reformers of the 18th, 19th and early 20th centuries (such as Wilberforce, Fry, Barnardo, Shaftesbury, etc) were Christians – mostly evangelicals or non-conformists. However, even Bevan had his values shaped in a Welsh upbringing influenced by chapel and the Welsh revivals.

If we are going to see reform in the NHS, it must keep these two elements together – social solidarity and professionalism. While a pure profit motive will never do this, many are setting up Community Interest Companies (CICs) that hold the values of service and social solidarity alongside professionalism and a social entrepreneurship that is creating innovative responses to real needs.

In Manchester, where health and social care budgets are combined and are being commissioned jointly in a trial known as DevoManc, I have seen some real examples of this. One such CIC was started off by a medical student on an Oldham council estate who saw the lack of local GP services in her community. She challenged the local commissioning group about this, and they instead got her to set up a practice to address the needs she saw. The model of whole person care that the practice developed (drawn from a Christian world view) involved working with local community groups, churches and others to address the social as well as health needs of the people on the estate. It was so effective that the CIC she founded to run the practice is now managing nine practices across Greater Manchester, specialising in providing health in areas of social deprivation.

They have gone on to developed specialised community services such as Focused Care to help patients who have difficulty accessing services and complying with treatment. This service marries health and social services in an innovative, family focused approach to supporting patients with complex health and social needs.

This example shows how a private company can be moved, not by a profit motive, but by the ethos of care and compassion at the heart of the NHS’s founding principles. It also shows how small bodies can innovate in a way that larger organisations can sometimes struggle to emulate.

There are many other such innovations that should be part of the fresh thinking needed for health service reform. That many (though not all) of these are faith based should come as no surprise. The church has owned the ethos of social solidarity since it began two thousand years ago. Simply because it is the natural outworking of the gospel of Jesus Christ.

So, Mr Hunt, if you are listening as you survey your expanded DHSC kingdom, you would do well to come and talk to those out in the community who are already re-imagining health and social care, many of whom do so in service of another, much greater Kingdom.

]]>https://cmfblog.org.uk/2018/01/12/reshuffling-health-and-social-care-finding-models-that-work/feed/0Let’s not go back to Gin Lane – once again it’s time for government to rethink alcohol policyhttps://cmfblog.org.uk/2017/07/24/lets-not-go-back-to-gin-lane-once-again-its-time-for-government-to-rethink-alcohol-policy/
https://cmfblog.org.uk/2017/07/24/lets-not-go-back-to-gin-lane-once-again-its-time-for-government-to-rethink-alcohol-policy/#respondMon, 24 Jul 2017 11:58:33 +0000https://www.cmfblog.org.uk/?p=11582‘History repeats itself.
Has to.
No-one listens’

It feels like déjà vu to once again see the headlines calling on the government to tackle alcohol related health problems. A study from the University of Sheffield shows that up to 68,000 people will die from alcohol related liver diseases in the next five years unless action is taken.

The solutions are not rocket science. Set alcohol prices at a minimum per unit (Minimum per-Unit Pricing or MUP), so that stronger drinks become more expensive. Better education around alcohol at school and in wider society – its health impacts, what constitutes safe consumption levels, etc. Public campaigns to make heavy drinking as socially unacceptable as drink driving.

While the Scottish and Welsh governments seem to be on a path to bringing at least MUP into effect (not without major struggles with the drinks industry), successive Westminster administrations have fought shy. This in the face of mounting evidence that not only is alcohol a major social, public health and economic problem for the UK, but that MUP has a demonstrable positive impact in all these areas. Not least because it most influences that large majority of drinkers who think of themselves as moderate drinkers, but whose consumption is actually borderline heavy to excessive.

Actually, I’m underestimating how far this goes back. Hogarth’s famous engraving Gin Lane (above) depicts the social chaos in Georgian cities caused by access to cheap alcohol. Awful social and economic circumstances faced by the poor drove many to the gin houses to escape. The churches realised the damage, and the result was the various temperance movements, the beer brewing industries, and various social reforms that sought to mitigate both the cause of problem drinking and the access to cheap, strong spirits.

Once again the church needs to be at the vanguard. We are out there on the streets in city centres with groups like Street Pastors and Street Angels caring for those who have been out drinking heavily all night. The churches have been lobbying government for action for years as well. I think we have something positive to contribute in the areas of education and tackling the root social and (dare I say it!) spiritual causes of problem drinking as well. We certainly are in the wider area of substance abuse.

I fear that we will return to this issue, but today’s report from the University of Sheffield is another arrow in the quiver to influence government alcohol policy. But while we wait for government to engage, maybe it is time that the church re-engaged and broke this repetitive cycle once and for all.

]]>https://cmfblog.org.uk/2017/07/24/lets-not-go-back-to-gin-lane-once-again-its-time-for-government-to-rethink-alcohol-policy/feed/0Family planning – ‘summit of a mess’https://cmfblog.org.uk/2017/07/18/11575/
https://cmfblog.org.uk/2017/07/18/11575/#respondTue, 18 Jul 2017 09:25:32 +0000https://www.cmfblog.org.uk/?p=11575Last week’s London Family Planning Summit was, on the surface, a ‘successful’ follow up to the 2012 Family Planning Summit, which aimed to increase access to contraception for 120 million women. US$2.5 billion was pledged by governments and other donors to ‘improve and expand the reach of reproductive health services to women and girls in developing countries’. The UK’s own Department for International Development (DFID) pledged £45 million to this fund.

In part, the need to commit extra funding has been driven by the US administration’s resumption of the so-called Mexico City Protocol that denies funding to any family planning organisation that offers or promotes abortion as a family planning strategy. This means that UNFPA and other groups could lose up to 47% of their funding. The Swedish Government has swung the other way and is refusing to fund any agency that doesn’t promote abortion!

The Gates Foundation has been at the heart of both summits. In an attempt to steer a low controversy, middle ground, Melinda Gates has maintained throughout that family planning does not include abortion, and that indeed, increasing access to contraception decreases the need for, and thus the incidence of, abortion.

Anne Furedi, coming from a strongly pro-abortion position, argues that this is nonsense – just look at the UK’s 200,000 abortions a year, despite high access to free contraception she argues. Contraceptives fail, women make other choices, and so abortion will always be part of the mix.

The Summit promoted the idea that family planning is vital to economic development. Reduction of family size is linked with increased prosperity, they argue. However, the evidence seems to show that it is the increased prosperity that leads to reduced family size – not the other way around.

It’s all a bit messy really, especially as the Gates Foundation’s partners in the summit include UNFPA and Marie Stopes International, who are very much for abortion as part of their reproductive health strategy. And there is quite a troubling legacy in the history of many of these organisations with which many developing countries live to this day.

But abortion is not the only issue that will give Christian organisations pause for thought. While there are a spectrum of beliefs and approaches to helping families in developing countries plan and space the births of their children, all Christian groups unite around some core values. Firstly, that human life is sacred, from womb to tomb. That human sexuality is gift from God and is best expressed in marriage (one woman, one man, for life). That marriage is a core unit of family (with both biological and adopted children), and family is a core unit of society.

Around these beliefs we can work together and with other bodies. We certainly should be working with churches and church leaders to get sexual and reproductive health messages out to their congregations and communities that bring together Christian teaching and science.

Unfortunately, the community and family based focus that Christians have is at odds with the individualistic, human rights based approach of most of the family planning community. As one African commentator put it recently, this current push for family planning is another form of Western, ‘ideological colonisation’. For that reason alone, it is unlikely that much of this extra pledged funding will make its way to Christian organisations, which may be a blessing in disguise.

As we have blogged before, the population control lobby have seen reducing the size of the world’s poor populations as vital to the future development of humanity. We are seeing the legacy of this thinking now in the developed world (especially Korea and Japan), where a shrinking birth rate (and indeed, marriage and sex rate!) sees an ageing population with a rapidly dwindling working age population. Migration is mitigating that problem for Europe and America to some extent, but that also drives other social problems.

The disproportionate number of boys and young men to women, especially in China and India, also driven by the policies of the family planning community, are creating huge social problems.

Christian organisations and churches should be involved with family planning and sex education, because we have a better story to tell. That we have not told it for far too long is our failing.

]]>https://cmfblog.org.uk/2017/07/18/11575/feed/0Where have all the nurses gone? NMC survey reveals an accelerating attrition of nurses and midwiveshttps://cmfblog.org.uk/2017/07/03/where-have-all-the-nurses-gone-nmc-survey-reveals-an-accelerating-attrition-of-nurses-and-midwives/
https://cmfblog.org.uk/2017/07/03/where-have-all-the-nurses-gone-nmc-survey-reveals-an-accelerating-attrition-of-nurses-and-midwives/#respondMon, 03 Jul 2017 13:12:59 +0000https://www.cmfblog.org.uk/?p=11529It seems sadly ironic that a week after Lord Crisp announced plans for a worldwide campaign to promote the value of nursing in global health and development, the UK’s Nursing and Midwifery Council announced that in the last year 1,783 more nurses and midwives have left the professions than joined for the first time in over a decade.

Inevitably this has fed into the current calls for an end to the public sector pay cap, for more certainty about the future of EU nationals working in the UK after Brexit, and to reinstate bursaries for student nurses, etc.

Dig into the figures however, and a more complex picture emerges. Not least is that this is not a new story – the concerns about training, recruitment and retention of nurses and midwives go back several years.

First, those that are leaving in largest numbers are nurses first registered in the UK. Of the 35,000 nurses and midwives leaving the register in 2016/2017, over 29,000 were British. We have known for some time that fewer EU nationals are applying for nurse jobs in the UK, and many are leaving. However, EU nationals make up barely 4% of the nursing workforce. Filipinos, Pakistanis and Indians are a bigger proportion of the workforce, and NHS trusts are increasingly going to those countries to recruit.

However, over 85% of nurses and midwives working in the UK are British nationals. This then is not primarily a Brexit crisis, although uncertainty around Britain’s departure looks to be a minor contributory factor.

Second, among those who have been surveyed about their reasons for leaving, pay was not the primary cause. About half are leaving because of retirement, and of those leaving for other reasons, only 18% rank pay and benefits as their main reason. Working conditions, including staffing levels, were the biggest reason for non-retirees leaving the profession.

But the main reason most give for leaving is stress and finding the workload, short staffing and pressures too much to manage (44% of those leaving for reasons other than retirement). Secondarily, many cite that not being able to give the level of care they want to because of these pressures has made it impossible for them to carry on their work. New research suggests that the prevalence of twelve hour shift patterns is adding to this unmanageable stress load. When the very nature of the system stops health professionals from feeling able to do their job properly, then questions need to be asked.

The Government says that there are more than 13,000 more nurses working on our wards than in 2010, and that there are 52,000 students in training. However, with an estimated 40,000 nursing and 3,500 midwifery vacancies unfilled in England alone, those assertions are disputed. It is therefore not too hard to see why staffing is a contributory factor in workplace pressures.

More troubling still is the profile of those leaving. The average age is 51 – that’s four years younger than the average age of leavers in 2012-2013. We have long known that we are facing a retirement cliff edge, with one in three nurses due to retire in the next decade. Thus the majority of those leaving are experienced, skilled nurses and midwives. That experience is not quickly replaced, and the attrition of experienced, skilled staff will have a real impact. The even bigger worry though, is the number of younger nurses that are leaving. This has doubled in the last three years. This means fewer staff building up the skills and experience in the long-term to replace those reaching retirement.

The other concern is the reduction in people applying to train as nurses or midwives. Since the abolition of bursaries last year, there has been a 23% drop off in applications. Anecdotal evidence suggests that tuition fees and stacking up major debts to train for a relatively low paid job is putting off many prospective students. Whether the shortfall continues past this year we wait to see, although the government remains confident that student numbers will pick up over the next couple of years. Whether there will be the funding for clinical placements for those students is another issue vexing universities.

Finally, the survey reveals that about 4,000 nurses and midwives have left the UK to work overseas. In particular they are heading off to Australia, the USA and Ireland. While the UK has been a net recipient of migrant nurses over the years, are we now moving towards being more of an ‘exporter’? This also highlights how internationally mobile the nursing workforce is. If the UK does not provide the best work environment, many will up stakes and move to parts of the world that offer better working conditions and pay. The NHS has to compete globally for nurses and midwives.

This is a complex issue that has been brewing for many years. As I said, it is also ironic that a parliamentary committee produced a report not twelve months ago that showed the way to improve a nation’s health, economic and social development and improve the status of women, was to invest in nursing and midwifery. Despite successive British governments promising that they will do / are doing this, the evidence is stacking up that they have not really succeeded.

Where do we go from here?

We can continue to recruit from non-EU countries. While this has benefits, it also adds to the brain drain from many developing nations. The nursing workforce is globally much smaller than needed. Our struggle to recruit can only be addressed in the long-term by tackling this global nursing shortage.

We could invest in training nurses and reinstating bursaries, but we were already struggling to fill nursing places before bursaries were introduced. We could scrap the 1% public sector pay cap, but this would cost the government £9 billion according to the IFS, and for now the government is ruling that out as an option.

The question is, as always, from where will the money come to pay for any or all of this? So the first issue to address is, what kind of healthcare system do we need, and how are we willing to pay for it? The answers today will be quite different to those raised at the birth of the NHS in 1948.

Second, the core values of the nursing profession are deeply Christian in their origins. However, the increasingly technical, acute and high throughput model of medicine under which the NHS operates makes this hard to live out in practice. This dissonance between the values of patient centred, whole person care on the one hand and a technological, protocol driven medicine on the other is increasingly difficult for nurses (and other health professionals) to live with. Until we can address this dissonance and answer what kind of model of health care we really want and can deliver, we will continue to struggle with a long-term solution.

In the meantime, the church can do a lot to support its own health workers – spiritually through flexible worship and home/prayer group arrangements that take into account shift patterns and anti-social hours, and creating groups specifically for health professionals to support one another.

Churches can be sources of encouragement and thanks to the wider community of NHS staff – making sure that health professionals and other NHS staff in their communities get thanks and encouragement regularly for the work they do.